Acutely Symptomatic Hypoperfusion Through an Occluded Subclavian to Internal Carotid Artery Bypass Graft: Salvage Mechanical Thrombectomy and Graft Revascularization

This middle-aged patient had undergone surgical placement of a left subclavian to internal carotid artery bypass graft five years ago for treatment of symptomatic, chronic, bilateral carotid occlusions. The patient was neurologically intact after the procedure and until the day of presentation with symptoms of an acute left anterior circulation stroke. Initial workup confirmed acute occlusion of the graft as the cause of the patient's symptoms. Endovascular recanalization of the bypass graft in the setting of chronic bilateral carotid occlusions was a technical and conceptual challenge. Simultaneous radial and femoral vascular access allowed for direct recanalization of the graft (through thrombectomy, angioplasty, and stent placement) with intraoperative patency surveillance of the circle of Willis via the posterior circulation. Most of the neurological deficits improved, and the patient was discharged to rehabilitation close to neurologic baseline.